Modified Bentall Procedure Using Two Short Grafts for Coronary Reimplantation: Long-Term Results

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1 Modified Bentall Procedure Using Two Short Grafts for Coronary Reimplantation: Long-Term Results Pablo Maureira, MD, Fabrice Vanhuyse, MD, Cécile Martin, MD, Malik Lekehal, MD, Jean-Pierre Carteaux, MD, PhD, Nguyen Tran, PhD, and Jean-Pierre Villemot, MD, PhD Department of Cardio-Vascular Surgery, University Hospital, Nancy; and School of Surgery, Faculty of Medicine, University Henri Poincaré, Nancy, France Background. The modified Bentall procedure remains a gold standard of aortic root surgery. We present in this study the early and late outcomes of a particular modification using 2 separated grafts for the coronary reimplantation. Methods. From 1995 to 2009, 153 patients aged (mean standard deviation [SD]) underwent elective (n 113) or urgent (n 40) aortic root replacement with a composite mechanical valve conduit reconstruction using 2 short, separated 8-mm Dacron grafts for the coronary reimplantation and were retrospectively reviewed. Results. Aortic disease etiologies were annuloaortic ectasia (n 108), type A aortic dissection (n 38), aortic false aneurysm, or Valsalva aneurysm evolution after previous cardiac surgery (n 7). The overall early mortality was 8.5% (20% for urgent procedure and 4.4% for elective procedure). For the whole group, actuarial survival at 5 and 10 years was 86.3% 2.78 and 73.7% 4.23, respectively. Among the 23 late deaths, 9 were valve-related deaths (stroke, n 3; endocarditis, n 1; unknown, n 5). During the follow-up, linearized rates of major bleeding, thromboembolism, and endocarditic evolution were, respectively, 1.3 %/patient-years, 0.42 %/patient-years, and 0.22 %/patient-years. One patient presented a nonseptic false aneurysm of the right coronary anastomosis and no structural valve dysfunction has been diagnosed. In total, only 2 patients required an aortic root reoperation. Conclusions. The modified Bentall procedure using 2 separated grafts for the coronary reimplantation is a feasible, safe, easy, and reproducible operative technique for aortic root surgery. (Ann Thorac Surg 2012;93:443 9) 2012 by The Society of Thoracic Surgeons In 1968, Bentall and De Bono [1] first described a surgical technique of composite mechanical valve conduit replacement for an aortic root aneurysm, and this operation has since been considered as a gold standard for the treatment of combined aortic valve and root disease. However, to minimize the tension at the site of coronary reimplantation and to prevent postoperative bleeding and pseudoaneurysm formation various modifications from the original description have been proposed. Among them, the Cabrol technique (Cabrol and colleagues [2]) and Svensson and colleagues modifications [3] are of particular interest in that they decrease the coronary tensions in the suture lines but need the use of a long graft prosthesis, increasing the risk of thrombosis and the operative technical difficulties. Coronary ostial reimplantation using the button technique has shown excellent midterm results [4 7]; however, in some very large root or in complex situations such as redo or type A dissection the coronary buttons might be difficult to mobilize and to reimplant without any suture tension. To minimize any tension in the suture line of coronary anastomosis, in 1982 Piehler and Pluth [8] published a Accepted for publication Nov 2, Address correspondence to Dr Maureira, Department of Cardio-Vascular Surgery and Cardiac Transplantation, CHU-Nancy, Hôpital de Brabois, Allée du Morvan, Vandœuvre Cedex, France. technique using a short 6-mm Gore-Tex to reimplant the left main coronary. In our institution, to prevent thrombosis of coronary graft with the Cabrol procedure, we have introduced, since 1989, a modified technique of the Cabrol procedure as an alternative solution, using 2 short separated grafts to reimplant the 2 coronaries, avoiding the risk of kinking, tension in the suture line, and risk of thrombosis. Presently, we continue to use this technique in different etiologies involving the ascending aorta and the root when we think that a valve sparing could be hazardous. In this particular and challenging field, the aim of this study was to evaluate the early and long-term outcomes obtained in our center concerning this particular modified Bentall technique. Patients and Methods Patient Characteristics The study design was approved by the Nancy-Lorraine ethical committee. From January 1996 to December 2009, 153 consecutive patients (131 men and 22 women, mean age 57 12) underwent a modified Bentall procedure using 2 shorts grafts for coronary reimplantation in the Department of Cardiac Surgery of the University Hospital of Nancy. The main preoperative characteristics of the patients are depicted in Table 1. Aortic disease etiologies 2012 by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 444 MAUREIRA ET AL Ann Thorac Surg MODIFIED BENTALL PROCEDURE: LONG-TERM RESULTS 2012;93:443 9 Table 1. Preoperative Patient Characteristics Variable Value % Sex ratio (male/female) 131/ %/14.4% Mean age, years (SD) Range (years) Previous cardiac surgery 7 4.6% Cardiovascular risks factors Hypertension % Coronary artery disease % Cerebral vascular disease 6 3.9% Peripheral vascular disease 4 2.6% History of smoking 16 10% Diabetes mellitus % COPD 16 10% Hypercholesterolemia 35 23% History of dysrhythmia % Severe renal insufficiency 5 3.3% Preoperative symptoms Chest pain % NYHA class (chronic status) I % II % III % IV 9 5.9% Left ventricle ejection fraction (mean SD) Aortic root disease Maximal aortic diameter, mm (mean SD) Marfan syndrome % Aortic dissection % Annuloaortic ectasia % Proximal false aneurysm 4 2.6% after previous cardiac surgery Valsalva aneurismal 3 1.9% evolution after previous cardiac surgery Aortic regurgitation Minor or mild % Moderate % Severe 52 34% Aortic descending aneurysm 5 3.2% Aortic abdominal aneurysm 4 2.6% COPD chronic obstructive pulmonary disease; Heart Association; SD standard deviation. NYHA New York were annuloaortic ectasia (n 108), type A aortic dissection (n 38), aortic false aneurysm after previous aortic root surgery (n 4), and Valsalva aneurysm evolution after previous cardiac extraaortic root surgery (n 0.3). Surgical Procedure All the procedures were performed by standard median sternotomy. In case of annuloaortic ectasia disease, normothermic extracorporeal circulation was installed between the right atrium and the ascending aorta, and myocardial protection was achieved by retrograde infusions of hypothermic blood cardioplegic solution. When the patients presented an aortic dissection or an aortic root redo surgery, arterial femoral cannulation was performed and deep hypothermia (18 C) circulatory arrest with retrograde (through the superior vena cava) or anterograde (selective carotid canulation) cerebral perfusion (mean flow of 10 ml/kg body weight) was applied when an arch replacement was required. The aorta was transected beneath the aortic clamp and proximally at the sinotubular junction. After exposition of the aortic root with stitches, an aortic valve evaluation was performed and valve replacement was decided in cases where a conservative procedure is not recommended. Then, after excision of the aortic valve, measurement of annulus diameter determined the size of the composite graft. Then, Dacron 8-mm grafts were sewn; one to the left main ostium and the other to the right coronary ostium with a 6-0 Prolene (Ethicon, Somerville, NJ), taking up all the layers of the aortic wall (Fig 1). The suture lines leak between coronary ostia and the Dacron graft were verified by a high pressure infusion of cardioplegic solution injected directly into the grafts (anterograde perfusion). Then, 3-0 stitch pledgets were placed in the aortic annulus (pledgets behind the annulus; Fig 1) and the graft composite was attached. To define the exact length of the coronary graft, we fill out the composite graft and we cut the grafts to avoid any tension; in general 2 or 3 rings (4 to 10 mm length). Then, the 2 grafts were sutured laterally to the composite graft perpendicularly with 5-0 Prolene (Fig 1). Once again, we tested the sutures, injecting high pressure cardioplegic solution directly into the composite graft to control any leakage between coronary graft and composite graft. The distal anastomosis was performed with 5-0 Prolene. Wrapping of the distal anastomosis could be done with the residual Dacron composite graft to decrease the tension of the distal suture line in order to prevent distal false aneurysm. Postoperative Anticoagulation Management All patients were given anticoagulant therapy with intravenous heparin immediately after the surgery if the bleeding was acceptable (2 mg/kg per 24 hours) and with anti-vitamin K (Fluindione; Warner Chilcott, Dublin, Ireland) postoperatively on the third day at the earliest. The international normalization ratio (INR) was controlled and heparin was interrupted if the INR target between 2 and 3 was reached. Aspirin (75 mg per day) was associated when a patient presented more than 2 cardiovascular risk factors. Follow-Up Patient status in this cohort was assessed according to retrospective chart review, missed patient questionnaires being completed by telephone and mail. The international normalized ratio was routinely accessed by the general practitioner and an echographic evaluation was performed once or twice a year for all patients. All valve-related deaths and all cardiovascular complications were identified in compliance with the guidelines estab-

3 Ann Thorac Surg MAUREIRA ET AL 2012;93:443 9 MODIFIED BENTALL PROCEDURE: LONG-TERM RESULTS 445 Fig 1. Operative technique. (A) Pledgets placed behind the aortic annulus; (B) two short Dacron 8-mm grafts sutured laterally to the composite grafts; (C) last step: the distal anastomosis; (D) final result. (Ao aorta; LV left ventricle.) lished by the Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity and Mortality [9]. Before hospital discharge, each patient was controlled by a computed tomographic (CT) scan (Fig 2). All patients benefited from a clinical (100%) and thoracic CT-scan (78%) follow-up in the Cardiac Surgery Department of Nancy or by their referring cardiologist. The database we used was updated using the software that our department has used since 1995 and a cross-sectional follow-up was conducted between September and December 2010 with a common closing date set at September 1, Follow-up was completed for 98.3% of the patients with a mean follow-up of years (range, 0 to 16.9 years) for a total of 945 patient-years of data available for analysis. Statistical Analysis Morbidity analysis included all cardiovascular complications as defined in the Guidelines for Reporting Morbidity and Mortality after Cardiac Valve Operations [9], plus false-aneurysm anastamosis evolution. Mortality and morbidity data were analyzed by the Kaplan-Meier actuarial method for estimation of survival probabilities. The probability of freedom from the first occurrence of each complication was graphically represented with regard to the follow-up time and expressed with corresponding standard error of the mean. Each adverse event (death, thromboembolism, major bleeding, endocarditis, structural dysfunction, false aneurysm) was summarized by means of a linearized rate, calculated as the number of events divided by the total number of patient-years (cumulative follow-up). Descriptive statistics (Tables 1, 2, and 3) were provided for continuous variables (mean, standard deviation, range), and for categoric variables (frequency, percent). Results Early and Late Mortality The 30-day in-hospital mortality was 8.5% (n 13). This rate reached 20% (n 8) for urgent procedure and 4.4% (n 5) for elective procedure. Causes of early death were post-dissection multiorgan failure (n 5), cardiogenic shock or myocardial infarction (n 5), and fatal hemorrhagic stroke (n 3). Long-Term Mortality For the whole group, actuarial survival at 5 and 10 years was 86.3% 2.8 and 73.7% 4.2, respectively. In case of urgent surgery actuarial survival at 5 and 10 years was

4 446 MAUREIRA ET AL Ann Thorac Surg MODIFIED BENTALL PROCEDURE: LONG-TERM RESULTS 2012;93:443 9 Comment Total aortic root replacement using a composite mechanical valve conduit has been used for 4 decades to treat combined aortic valve and ascending aortic disease, and different methods of coronary reimplantation have improved the results of the original technique [2 4]. In our center, in most of cases (around 70%), we have used a short Dacron graft to reimplant the right and left coronary arteries and this study supports that this particular technique can be accomplished with a low overall risk Table 2. Operative and Perioperative Data Operative Data Value % Fig 2. Postoperative three-dimensional computed tomographic scan assessment. 65% 7.5 and 60.9% 8, and in case of elective surgery actuarial survival at 5 and 10 years was 93.8% 2.3 and 80.5% 45 (comparison of survival curves with the log-rank test, p ) (Fig 3). Among the 23 late deaths (Table 3), 9 were valve-related; stroke (n 3), endocarditis (n 1), and unknown (n 5). Early and Late Morbidity Early complications are summarized in Table 2 and late main valve-related complications are summarized in Table 3. Risks of a first major hemorrhagic event, an embolic event, and a reoperation are represented in Figure 4. Linearized rates of major hemorrhagic complications (n 12; and among them 9 nonfatal complications), thromboembolic complications (n 4), and endocarditis with proximal false aneurysm (n 2) were, respectively, 1.27%/patient-years, 0.42 %/patient-years, and 0.22%/patient-years. Only one isolated nonseptic pseudoaneurysm was diagnosed (1.1%/patient-years) and no structural valve dysfunction occurred during this follow-up. In summary, linearized rate of composite valve graft-related complication was 2.1%/patient-years and is represented in Figure 4. In this series, 2 patients have been reoperated (endocarditis n 1, isolated false aneurysm n 1). Total % Elective/urgent 113/ %/26.2% mean bileaflet valve diameter size CarboMedics composite conduit % (CarboMedics, Austin, TX) St. Jude composite conduit (St % Jude Medical, Inc, St. Paul, MN) Associated procedure 17 11% CABG 8 5.2% Mitral valve repair/replacement 4 2.6% Aortic arch with supraaortic 3 2% reimplantation Carotid endarterectomy 1 0.7% Femorofemoral bypass 1 0.7% Aortic cross-clamp time (minutes) Cardiopulmonary bypass time (minutes) Hypothermic circulatory arrest % (selective or retrograde cerebroplegia) Perioperative data Transfusion requirement % Atrial fibrillation % Third-degree AV block (requiring % pacemaker) Reoperation for bleeding and/or 9 5.9% tamponade Myocardial infarction 2 1.4% Low cardiac output syndrome 4 2.6% Neurologic stroke 5 3.3% Renal insufficiency requiring 7 4.6% hemofiltration Severe respiratory complication 5 3.3% Mediastinitis 4 2.6% Endocarditis 1 0.7% Early mortality Total % Elective surgery 5 4.4% Urgent surgery 8 20% Multiorgan failure 5 3.3% Myocardial Infarction 5 3.3% Hemorrhagic stroke 3 2% AV atrioventricular; CABG coronary artery bypass grafting.

5 Ann Thorac Surg MAUREIRA ET AL 2012;93:443 9 MODIFIED BENTALL PROCEDURE: LONG-TERM RESULTS 447 Table 3. Late Mortality and Morbidity Long-Term Postoperative Outcomes Total % Late death (% 140 patients) % Valve-related death (% late death) % Unknown/sudden 5 Major bleeding 3 Valve thrombosis 0 Embolic event 0 Endocarditis 1 Cardiac-related death (% late death) 2 8.7% Extracardiac death (% late death) % Cancer 3 Miscellaneous 9 Late morbidity (% 140 patients) % Major bleeding 12 Valve thrombosis 0 Thromboembolic event 4 Endocarditis 2 Reoperation 2 CT-scan data (completeness/140 patients) % Coronaries reimplantation pseudoaneurysm 1 0.7% CT computed tomography. and indicates satisfactory long-term results. However, when the status of the urgent or elective surgery is taken into account, we observe a significantly higher difference concerning early mortality for urgent surgery (ie, for type A dissection [20%] than for elective surgery; ie, annuloectasia chronic aortic disease [4.4%]). High-rate mortality for the urgent group in our series is similar to the results presented in a recent study by Stamou and colleagues [10]. It is important to take this into consideration in our study because 40 patients (26%) have been operated in an urgent or emergency situation. This initial condition impacts on the long-term survival rate (5-year and 10- year survival rates of 86.3% and 73.7% for the whole group but only 65% and 60.9% in cases of initial urgent surgery). In 2007, Radu and colleagues [11] reported an actuarial survival rate at 5 years of 89.1% for a selected population, all of whom were electively operated exclusively using the button technique. However, in 2003 Pacini and colleagues [12] found actuarial survival rates of 77.7% and 63% at, respectively, 5 and 10 years for composite graft surgery, including 16% of acute dissection in a series concerning 274 patients. In 2004, Zehr and colleagues [13] presented the long-term results of 203 patients treated at the Mayo Clinic for aneurysm of the aortic root with composite graft (n 149) or valvepreserving aortic root reconstruction (n 54) with 5 and 10 years actuarial survival rates of 93% and 79%. However, only 12 patients (6%) were urgently operated and Zehr and colleagues clearly emphasized a rate of 11.7% of early mortality in this subgroup. Concerning late deaths, we have to also notice that, among 23 late deaths only 9 were valve-related but 5 were undiagnosed deaths, and we can also suspect a valve-related complication or aneurismal or dissection fatal evolution in this particular population. As described by others, this series supports the claim that valve conduit reconstruction is a durable technique. Only 2 patients in our study have been reoperated; 1 for prosthesis infection and only 1 for coronary anastomotic pseudoaneurysm. This low rate of reoperation is comparable with other modified Bentall operation techniques. We observed that the infectious complications arose after a particularly long hypothermic procedure (for acute dissection) and one of them needed a revision for bleeding after the initial surgery. Concerning the coronary reimplantation complication, commenting on this result could be hazardous. Indeed, as in many others published, the completeness of the systematic CT-scan control is not available to report a definitive result. However, it is well accepted that fatal evolution of this complication is lower with the button technique than with the classic Bentall or Cabrol modification. We think that our technique facilitated the coronary reimplantation by avoiding any suture tension. For all the situations, short Dacron grafts about 5 or 6 mm in length for left main and right ostia are sufficient to reach this objective. Moreover, the shortness of the Dacron graft prevents any kinking or graft thrombosis risk, preserving physiological coronary flow. To our knowledge, there is only 1 report presenting long-term results in a significant cohort; Hirasawa and colleagues [14] reported an excellent long-term result (actuarial survival rate 93% at 5 years) concerning 71 patients with no postoperative pseudoaneurysm or thrombosis. Regarding the technical aspect, we think that this technique is particularly useful in cases of very low type A dissection and for very large roots when the distance of the ostium is excessive, or redo situations Fig 3. Survival curves. (A) Overall survey (dark line) survival probability and (light line) 95% confidence interval. (B) Survey in case of urgent (dotted line) or elective (solid line) surgery.

6 448 MAUREIRA ET AL Ann Thorac Surg MODIFIED BENTALL PROCEDURE: LONG-TERM RESULTS 2012;93:443 9 Fig 4. Long-term composite graft-related complications (dark line) survival probability and (light line) 95% confidence interval. (A) First major bleeding event. (B) First embolic event. (C) Reoperation. (D) Fatal and nonfatal valve-related event. (n 7 in this study) when the presence of epicardial adherences increases the dissection of the buttons and reimplantation difficulty. This objective was the same as the Cabrol modified technique ; however, the long graft used in this technique could be hazardous. Shortness of the Dacron prosthesis is an important issue in minimizing the risk of local acute thrombosis or graft kinking, hypothetical dramatic adverse effects that we have not observed in this series. We think too, that the avoidance of any tension at the suture line can decrease the hemorrhagic risk. This has been observed in the elective group. Compared with the button technique, clamping time can be increased by the preparation of the short grafts and the 2 suture lines. However, it is not necessary with our technique to dissect the coronary ostium and clamping time is longer depending on associated procedures (coronary artery bypass grafting, mitral surgery) and particular conditions (redo, acute dissection) than in root reconstruction itself. We report in this series satisfactory rates of major thromboembolism and major bleeding events compared with the series of Radu and colleagues [11] (respectively, 0.42% vs 1.1%/patient-year and 1.3% vs 2.2%/patient-year). Among these particular complications, only 3 have been fatal related to massive hemorrhagic strokes. We noticed that strokes concerned older patients with severe hypertension treated by at least 3 medications. In a previous report, where we analyzed mechanical valve-related events, we pointed out the same problem especially in patients over 70, but with rates inferior to the results found in this study [15]. One hypothesis is that in our center, when we make an isolated aortic valve replacement, we widely accept INR between 1.8 and 2.5 although after composite valve graft reconstruction we are stricter in obtaining an INR between 2 and 3. However, our thromboembolism rate remains relatively low although composite graft and multiple anastomoses have been shown to promote thrombus formation [16, 17]. Wecan remark that we used composite mechanical valve grafts, even in older people (maximum 79 years old) but we recommend using a composite biologic valve graft (or to construct it) for elderly patients or when the hemorrhagic postoperative risk is severely increased, as has been proposed by others [18]. Another issue concerning aortic root surgery is in the precise indication of a composite valve graft reconstruction compared with a valve-preserving aortic root in urgent situations or young patients. This question is not the purpose of this study but we would like to emphasize once again the low rate of reoperation and the relative ease with which this technique can be reproduced. Finally, we have to mention some of the principal limitations of this retrospective study. First, it concerns a particular technique applied to a very heterogeneous population in acute or chronic situations. Second, CT-scan annual controls were available for 110 patients out of 140 in the postoperative assessment (78.5%) and we cannot exclude asymptomatic pseudoaneurysm evolution in the uncontrolled fraction. Third, we recognize that some variables have not been analyzed; ie, the existence of Marfan disease, connective tissue disorders, severity of hypertension, and the medical therapy, which may have been underestimated in this study. In addition, interpretation of evolution of aneurismal disease and cardiovascular events during the follow-up is difficult because of the lack of histologic and genetic data. In conclusion, this series confirms that composite graft valve replacement can still be considered as a gold standard for aortic root disease surgery and supports that the modified Bentall technique using 2 separated Dacron grafts is a simple, reproducible, and safe operative technique.

7 Ann Thorac Surg MAUREIRA ET AL 2012;93:443 9 MODIFIED BENTALL PROCEDURE: LONG-TERM RESULTS 449 References 1. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23: Cabrol C, Pavie A, Gandjbakhch I, et al. Complete replacement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach. J Thorac Cardiovasc Surg 1981;81: Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients. Ann Thorac Surg 1992;54: Kouchoukos NT, Marshall WG Jr. Treatment of the aortic ascending dissection in Marfan syndrome. J Card Surg 1986;4: Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen-year experience with aortic root replacement. Results of 172 operations. Ann Surg 1991;214: Ergin MA, Spielvogel D, Apaydin A, et al. Surgical treatment of the dilated ascending aorta: when and how? Ann Thorac Surg 1999;67:1834 9; discussion Guilmet D, Bonnet N, Saal JP, Le Houerou D, Ghorayeb G. Long term survival with the Bentall button operation in 150 patients. [Article in French] Arch Mal Coeur Vaiss 2004;97: Piehler JM, Pluth JR. Replacement of the ascending aorta and aortic valve with a composite graft in patients with nondisplaced coronary ostia. Ann Thorac Surg 1982;33: Akins CW, Miller DC, Turina MI, et al. Guidelines for reporting mortality and morbidity after cardiac valve interventions. Ann Thorac Surg 2008;85: Stamou SC, Kouchoukos NT, Hagberg RC, et al. Does the technique of distal anastomosis influence clinical outcomes in acute type A aortic dissection? Interact Cardiovasc Thorac Surg 2011;12: Radu NC, Kirsch EW, Hillion ML, Lagneau F, Drouet L, Loisance D. Embolic and bleeding events after modified Bentall procedure in selected patients. Heart 2007;93: Pacini D, Ranocchi F, Angeli E, et al. Aortic root replacement with composite valve graft. Ann Thorac Surg 2003;76: Zehr KJ, Orszulak TA, Mullany CJ, et al. Surgery for aneurysms of the aortic root: a 30-year experience. Circulation 2004;110: Hirasawa Y, Aomi S, Saito S, Kihara S, Tomioka H, Kurosawa H. Long-term results of modified Bentall procedure using flanged composite aortic prosthesis and separately interposed coronary graft technique. Interact Cardiovasc Thorac Surg 2006;5: Villemot JP, Lekehal M, Maureira P, et al. Nine-year routine clinical experience of aortic valve replacement with ATS mechanical valves. J Heart Valve Dis 2008;17: Bonnefoy A, Liu Q, Legrand C, Frojmovic MM. Efficiency of platelet adhesion to fibrinogen depends on both cell activation and flow. Biophys J 2000;78: Ballyk PD, Walsh C, Butany J, Ojha M. Compliance mismatch may promote graft-artery intimal hyperplasia by altering suture-line stresses. J Biomech 1998;31: Urbanski PP, Heinz N, Zhan X, Hijazi H, Zacher M, Diegeler A. Modified bio-bentall procedure: 10-year experience. Eur J Cardiothorac Surg 2010;37: INVITED COMMENTARY Reconstruction and repair of proximal aortic root pathologies continues to evolve. The original Bentall technique involved direct reimplantation of the coronary arteries and was later modified by mobilization of each coronary ostium for direct ostial implantation as buttons attached to the root graft. The later Cabrol technique sought to reduce tension to the coronary reimplantation by using a second small graft with end- to-end anastomosis to the coronary ostium and then a side-to-side anastomosis to the aortic root prosthesis. Numerous variations of these techniques have been proposed to facilitate root reconstruction, but the majority of root replacements performed in this era use the modified Bentall technique with mobilization of the coronary ostium and direct implantation as buttons. Maureira and colleagues [1] have provided a singleinstitution review of their experience with a modified Bentall procedure: Two short grafts are anastomosed to each coronary ostium and then separately reimplanted onto the aortic root prosthesis. The institution reviewed 153 consecutive patients in whom this technique was used on various aortic pathologies, with admirable results. For their entire cohort, actuarial survival at 5 and 10 years was approximately 86% and 73%, respectively. Excluding the highly morbid emergent surgeries (mostly type A dissections), those numbers were an impressive 94% and 81% survival, respectively. The authors have demonstrated that their technique is safe and comparable to other modified Bentall procedures. The real question is one of technical necessity. The treatment of all aortic root reconstructions with the authors technique is not necessary because the simpler button technique is possible. Therefore the authors technique adds additional complexity and risk to the operation. Although the authors mention in the discussion the minimal added time required, the addition of an interposition graft for each ostium requires additional suture lines, sizing time, and graft preparation, which prolongs myocardial ischemic and operative time. While this technique may not be appropriate for all patients requiring aortic root reconstruction, those cases with difficult mobilization of coronary ostium, such as root reoperations and type A dissections, may benefit from the use of this procedure. Therefore adding this specific modification of the Bentall procedure to the surgeon s armamentarium may prove valuable. Derek R. Brinster, MD Divisions of Cardiothoracic and Vascular Surgery Virginia Commonwealth University Medical Center Medical College of Virginia Campus West Hospital Building, 7th Floor, South Wing 1200 E Broad St PO Box Richmond, VA dbrinster@mcvh-vcu.edu Reference 1. Maureira P, Vanhuyse F, Martin C, et al. Modified Bentall procedure using two short grafts for coronary reimplantation: long-term results. Ann Thorac Surg 2012;93: by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur